1.5.13

REACHING OUT

Johns Hopkins pediatrics, once considered a Baltimore-only brand, is coming soon to a neighborhood near you.

--by Mat Edelson

At what point does desire become a movement, or the compassion of one morph into a clinical and administrative force helping countless thousands? These are not academic questions, but rather the current point in time at which the 20-year-old Johns Hopkins pediatric network finds itself.
The
network, whose grassroots could in all fairness be described as a dozen
different deals made by a dozen different doctors in a dozen different ways, is
nonetheless impressive in its scope, providing clinical services at more than 25
sites across Maryland. Nor does the network stop at the Free State’s borders.
From Florida to Chile and the United Arab Emirates, hospitals and their
leadership are reaching out to Johns Hopkins for pediatric expertise and faculty. In
return, Hopkins is gaining a clinical and financial foothold in far-flung communities
that once thought of Hopkins pediatrics as
being a Baltimore-only brand. With $12 million in annual revenue and counting,
one thing is for certain: This is a network worth watching.

***

They
say all politics is local, but pediatrics may be even more
neighborhood-oriented. At the heart of the Hopkins pediatric network is the
bond between families, their local pediatricians, and the down-the-block
community hospitals and clinics that service these physicians and patients. In
the 1990’s, long before the network even had a name, Hopkins pediatric
administrators realized they’d have to scatter their clinical seed deep into Charm
City’s suburbs and beyond if they were going to keep East Baltimore’s pediatric
beds filled.

“Pediatrics is local and our pediatric hospital admissions are far more
dependent upon community referrals than adult admissions,” says long-time Johns Hopkins Children’s
Center Administrator Ted Chambers. “Since
a pediatrician might admit only four or five patients a year out of hundreds
and hundreds of visits, the idea for us was to cast the net as wide as possible
to feed a hospital the size of Hopkins that handles 10,000 pediatric discharges
annually. That was the original premise for establishing the network.”

That, and the fact that Hopkins
pediatrics operates in one of the most competitive environments for beds in the
country. Unlike, say, Cincinnati, where pediatricians needing a hospital have
little choice but to send their patients to the only tertiary game in the
region – Cincinnati Children’s – a Maryland pediatrician has numerous options.

“We have University of Maryland downtown.
Children’s National in D.C,. CHOP (Children’s Hospital of Philadelphia) and
Dupont to the North, Children’s of Pittsburgh to the west, and Inova in
Virginia,” says Chambers. “And Sinai skims some cases as well. That’s a lot of
excellence, a lot of hospitals. It’s why we have 205 beds instead of 400. You
couldn’t. There’s too much competition.”

Thriving in that kind of competitive
environment meant developing an operational strategy that capitalized on
Hopkins’ strengths and the community’s needs. Chambers looked at the landscape
and saw that, on the whole, suburban areas and their hospitals lacked the specialty
care that area pediatricians desperately desired. At the same time, changes in
the nation’s medical system – which will accelerate under the Affordable Care
Act – dictated that care that could take place at the community level would be
reimbursed more than if those cases were automatically transferred to
tertiary centers.

Given those economic and clinical
realities, Chambers’ marching orders to the Children’s Center’s specialty divisions
were to find clinical opportunities in community settings, work with local
pediatricians and hospitals to treat in the community whenever possible, and
bring the truly tertiary and quarternary cases back to Baltimore.

Those were the networks’ immediate goals,
but Chambers also had long-term aspirations as embryonic partnerships evolved
into trusting relationships. They involved injecting Hopkins academic,
educational, and research energies into the community, and, in turn, being
looked upon by regional providers as the “go to” hospital for their most
serious cases. This model depended upon the Children’s Center implementing
infrastructure updates to the hospital itself to better serve regional needs,
with Chambers targeting the call center, patient transport, and internal
patient flow as being prime areas of improvement (see sidebar).

Chambers’ faith in
the faculty was such that he let them develop their community leads. The result
has been relationships that began in a rather ad hoc manner, but grew into
much, much more. Those casual conversations between old classmates, the
concerned midnight call regarding a confounding and perilous case, a wish to
keep a kid with a simple surgical issue close to home – all laid the groundwork
for formal partnerships in hospitals such as GBMC,
St. Agnes, Suburban, Howard County, and Frederick Memorial..

Create
Easier Access

In
terms of outreach, perhaps no Children’s Center physician understands the
importance of being accessible to the community more than pediatric
cardiologist Joel Brenner, who has been
offering his services around the state since 1977. To Brenner, the equation is
simple: “The reality is, pediatricians will send their patients to the most
convenient place they can get the fastest appointment. We need to meet that
requirement,” says Brenner, who has certainly done his part. Brenner services community clinics and
hospitals in Westminster, Frederick, Bel Air, Cumberland, and Towson. He says
the community pediatricians he works with are enticed by lower community based
costs, easier access to care, and telemedicine technology linking remote
sites directly to the Children’s Center.

“We have a huge infrastructure built into
our outreach,” notes Brenner. “I was in Frederick doing echo(cardiograms); that
machine plugged into the wall is also being read back at Hopkins, by echo
physicians downtown. I know we’re providing a better product, as opposed to the
single community providers who take and read echos by themselves. We have extra
coverage, extra depth, which protects against erroneous readings.”

Share
Surgical Services

At
GBMC, the need was surgical. Strategically, outpatient pediatric surgery is an
area of great interest to community hospitals like GBMC, but it’s also a bit
tricky, as few hospitals have pediatric intensive care units (PICUs) for cases
with complications. GBMC, under former Hopkins Robert Wood Johnson fellow and
Bayview faculty member Timothy Doran,
had built quite a surgical practice with a crackerjack pediatric surgeon who
was handling about 800 cases annually. When he announced his retirement, GBMC administrators
had a choice: Hire an independent surgeon with no tertiary care links, or align
with a surgeon who could handle all cases regardless of acuity.

Doran reached out to Ted Chambers with
the idea of finding a hybrid surgeon
who would handle cases at both GBMC, and, when necessary, the Charlotte R. Bloomberg
Children’s Center. That surgeon turned out to be Jeff Lukish, who now works half-time at GBMC, but whose salary is
paid for by Hopkins.

“It’s a win-win,” says Lukish, who has
helped build regional outpatient surgical suites at GBMC, Howard County General Hospital and Anne Arundel Medical Center. “If you are a mom or dad and you have a
child with a hernia, something straightforward, it is right to care for that
kid in an outpatient center in their community because it is less stressful,
the OR’s are not as booked, and the child gets in and out in a very efficient
manner.”

“If you structure it right, everyone
benefits,” agrees Tim Doran. “The advantage for us is we can offer bread and
butter pediatric surgery procedures here, but we can also have them evaluated
here, and, if need be, take them downtown for surgery at Hopkins.”

Build
Intensive Relationships

Another
key area of community partnerships for the network is consulting and, in some
cases, building and running neonatal intensive care units (NICUs). Hopkins neonatologist
Ned Lawson has worked with hospitals
including Sibley, St. Petersburg’s All Children’s, and Frederick Memorial on
their NICUs.

“Neonatal units are very popular among
hospital administrators because they tend to be very, very profitable.” says
Lawson. “Another reason is obstetricians (OBs) don’t like to refer mothers
(outside their region). If they’re having a premature delivery that really
wouldn’t work well in the hospital because it doesn’t have a NICU, that OB will
be in the face of administrator saying ‘You must develop a NICU so I don’t
(forfeit) a delivery.’”

For Frederick Memorial, developing a NICU
relationship with a tertiary care center such as Hopkins dovetails with its own
strategic goals. Utilizing Hopkins’ expertise, they’ve steadily advanced their
NICU’s level of acuity, where they are now certified to deliver babies as young
as 28 weeks. This allows OBs to do higher-risk deliveries locally, and keep
mothers and their newborns united.

“If a mother has twins, and one is fine
to go home but the other needs a NICU and is sent elsewhere, the mother is now
divided between two babies,” says nurse Katherine
Murray, who is the service line director for Frederick Memorial’s Women and
Children’s Programs. “Plus, there was an outcry from patients about not wanting
to have to travel to Baltimore.”

The success of Frederick’s NICU, which is
run by Hopkins’ neonatologists, is a model of how relationship building is
expanding the overall pediatric network. Murray says when other medical centers
with the hospital wanted to move into pediatrics, they called on her to explore
possibilities with Ted Chambers.

“Now our sleep center is both adult
and pediatric, we’re working with pediatric cardiology to do telemedicine
echocardiograms, and we’re trying to do an arrangement for pediatric
neurology,” says Murray, adding, “But it all started with the NICU.”

Knit
the Network

Between
wants and needs, supply and demand, and the sheer breadth of its reach, by 2010
Hopkins pediatric network had matured to the point where it needed organization
lest it be crushed by its own weight. Internally, formally recognizing and
naming the network two decades ago gave it important standing as the
third pillar alongside the Children’s Center hospital and the Pediatrics
Department. So too did Ted Chamber’s hiring of Deann Gavney as the network’s administrator, responsible for
streamlining the contracting process and creating economic efficiencies of
scale. Chambers candidly admits that, prior to Gavney’s arrival, the rapid
growth of the network was becoming problematic.

“It’s like Sherman’s March to the Sea.
Sometimes you get beyond your supply line,” Chambers concedes. “In our case, we got
beyond our infrastructure. We could not manage this enterprise the way we
needed to. We were not paying attention to details like we needed to, because
it had all been built ad hoc.”

Creating transparency and putting the network on sound financial footing will allow for Hopkins to
plan partnerships that might initially run in the red, but have solid long-term
potential. Such was the case with Howard County General’s Pediatric ED.
Originally a tiny three-bed unit, administrators hoped to expand it. But
instead of doubling the unit’s size, which would have pleased the
powers-that-be, Hopkins’ ED staff invested in a brand new 12-bed unit.

“They said, you could expand to five or
six beds, but really the long-term need is 12. And maybe you won’t use all
these beds right away, but we think this is where pediatrics in the community
should go and will go,’ says pediatrician Dave
Monroe, director of the Children’s Care Center at Howard County: “They
built us a gorgeous unit and within a year it was actually filled-up.”

Adds Peter Mogayzel, vice chair for the network, “The hope
of the network is that as we merge all the finances together from different outreach programs, some will do better than others and therefore we can
offset a loss with a gain. So overall we can provide more services than if
each venue needed to show a financial gain on its own.”

Nonetheless, Mogayzel adds, the goal is not to saturate the state with Johns HOpkins clinical services but to work with community pediatricians to strategically fill specialty services where such care is needed.

"We are looking to the private practice pediatricians to identify the services that are really needed in their communities, the services that would be most beneficial to them, Mogayzel says. "It doesn't help them much if they need a pulmonologist and we give them a cardiologist."

Indeed, there’s more than money to this
story, as Chambers recently realized when he was deep into discussing the
network’s cash flow with Hopkins new 3.0 operating committee.

“All the leadership was there. They
stopped me in the middle and said, ‘You have to think more broadly than just dollars
and cents,’” recalls Chambers. “They said ‘We have a tripartite mission. So
when you’re running this network, it has to have a research component –
clinical trials involving big populations – and wherever you go you have to
have an educational and clinical safety component. Part of the goal is to
upgrade the quality of pediatric care in the community; you have to leave that
program better than you found it.’”

Export
Education and Research

In
some cases, that education occurs within Hopkins’ walls, where Critical Care
Medicine physician Betsy Hunt uses
the Simulation Center she directs to train area pediatricians, like those at Suburban
Hospital, on protocols. These include pediatric advanced life support for children
who are critically ill.

But just as often, that training occurs
at the hospitals within the Pediatric Network. St. Agnes has long been the home
to Hopkins’ hospitalist residency program, with Hopkins hospitalists also
running the unit. Compared to rotations that occur within the academic setting
of the Children’s Center, the pediatric residents that come through St. Agnes,
to a person, say they enjoy an unusual level of autonomy.

Working with hospitalists, “the residents
really run the show here. They enjoy the sense of responsibility and the
pressure that goes along with it,” says former resident and current St. Agnes
hospitalist Eric Balighian. “It’s
different than at Hopkins; there’s not always the best pediatric pharmacist or
best pediatric respiratory therapist in the world just down the hall. The
residents are forced to think about things themselves and come up with plans
and they appreciate learning about how pediatrics is really practiced in
communities, as opposed to Hopkins, which is unique. Here residents really get
to focus on clinical diagnosis.”

That education is supplemented by Hopkins
faculty who lecture at community hospital grand rounds. St. Agnes’ grand rounds
are often attended by area pediatricians, offering them the added benefit of
familiarization with Hopkins staff.

Then there’s the research side, which
brings Hopkins drive for patient- and family-centered care into the hospitals
with which they partner. At St. Agnes, “we just recently incorporated something
that they’ve been doing at Hopkins called the PHACES (PHotographs of Academic
Clinicians and their Educational Status)
project, where they have the pictures and names of all the attendings,
residents, and medical students on the wall of every patient’s room,” says
hospitalist Sheila Hofert, who is
working on her own research project, gauging the best way to deliver bad news
to patients.

Structurally, the network has made
important internal changes, for those times when community patients are
referred to beds within Hopkins. The call center and patient flow to open beds
have been revamped, as has the transport system to ensure rapid response
whether by air (helicopter) or land (with specially-equipped ambulances capable
of transferring babies weighing under a pound). Bruce Klein, director of Pediatric Transport Medicine, says their
goal is not only to be fast but to make that call as comprehensive and collegial as possible.

“We’re trying to make those calls
efficient, pleasant, providing everything an outside referrer might need in a
single call, including speaking, ideally, to the receiving physician and the
transport nurse,” says Klein.

With transports reaching new highs –
Klein says a second 12-hour team was recently added to handle the volume of
transports during the week – the network is poised to further extend its reach.
Discussions are underway with Suburban and Anne Arundel hospitals to expand
their specialty outreach, which Peter Mogayzel says could greatly benefit
Eastern Shore patients: “If you lived in Salisbury and needed specialty care,
you used to have come to Baltimore, to Orleans Street to be seen. And now we’re
saying, ‘No, you don’t necessarily need to do that. You can come to Annapolis,
because that’s a lot closer and easier for you, and we’ll have a number of
subspecialties there.’”

Think of it as Hopkins on-call. Coming soon
to a neighborhood near you.

##

(sidebar)

A
“Yes” Approach to Service

Any
organization is only as good as its infrastructure, so administrators for the Johns
Hopkins pediatric network have beefed up three key areas to ensure that
regional patients transferred to and from East Baltimore receive top quality
service. It all starts with the call center, where referring physicians and
nurses now have a one-stop shop for a child in need. By dialing 410-955-9444, or 1-800-765-5447 outside of the Baltimore area,
everything from emergency transport to doctor’s appointments can be scheduled,
with all calendars system-wide being kept within the call center. Not always
known for its customer service – several area physicians interviewed said they
had encountered inconsiderate and inaccurate service in the past – the Call
Center is moving in a positive direction under the data-driven leadership of
customer service professional Latisha
Smith.

“The goal is that callers are not kept
waiting, not going to voicemail, and not holding for long periods of time. We
want to get scheduling done in a timely fashion,” says Smith. “We’ve set up
phone metrics where 80 percent of our calls have to be answered within 30
seconds, and less than 3 percent of our calls end up being abandoned (where the
caller hangs up). We’re also saying ‘Thank you,’ getting callers’ names and
telephone numbers, getting them into the right clinic and meeting our goals for
each individual agent.”

Once those calls are received, it’s often
time for the emergency transport team to jump into place. Under the guidance of
pediatric emergency medicine physician Bruce
Klein and Medical Director Kristen
Nelson, the transport operates between East Baltimore and 50 regional
hospitals. Interestingly, Klein says that only 30 percent of all transfers go
directly to the Pediatric Intensive Care Unit; the rest are handled by
subspecialists within the Children’s Center.

The heart of the transport team is the
specialized group of 12 pediatric transport nurses who head out by ambulance,
helicopter, or, in long-distance cases, jet to make sure each child’s transport
goes smoothly and safely.

“The nurse is involved in the initial
call, so we get a very detailed description of the patient’s medical needs and
a system-by-system evaluation,” says interim nurse transport manager Philomena Costabile. “We like to say we
are prepared in knowing what we are going to get when we get to the hospital,
but sometimes that is not exactly the way it goes down. That’s why we work with
a team. When the nurses go out, there is always a paramedic and an EMT on
board, so collectively it’s our responsibility to assess the patient, do any
medical interventions necessary during transit, and communicate back to both
Hopkins and the original facility.”

In concert with the transport is the
knowledge that bed space will be available upon arrival. Efficiently managing
patient flow to discharge so those beds are open is the focus of a
collaborative initiative of four med-surg unit medical directors. Susan McFarland, Alia Irshad, Jessica Komlos,
and Sybil Klaus have been tasked
with getting patients ready for discharge before
noon, which is considered the golden hour for opening beds.

Currently, more than 83 percent of all
Children’s Center discharges take place after 12 noon, so there’s plenty of
room for improvement. Alia Irshad says the changes taking place include early
morning team meetings on each unit involving nurses, social workers, and
customer service representatives, “to figure out the barriers to a kid’s
discharge,” she says, noting that, in the case of children moving to rehab
outside Hopkins, timely communication with those rehab centers to fulfill their
information requirements for accepting a new patient is vital.

“This allows our
ICU beds to open up," says Irshad, "which facilitates transfers not just from our OR and ER,
but from community hospitals.”

In the case of children waiting to be
discharged home, McFarland notes that case managers and social workers have improved efficiency by taking care
of any home care, pharmaceutical, insurance and other needs well ahead of time. McFarland also cites a hospital-wide service excellence intitiative to conclude physician rounds by 10 a.m. each day, freeing up staff to release patients earlier in the day.

"Based on our data review, the medical teams are meeting this new goal of finishing rounds by 10 a.m.," says McFarland. "But there is still work to be done by all involved to find innovative and efficient ways to reach our goal."

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About Me

As a famous TV shrink once noted, the key to a full life is "A little song, a little dance, a little seltzer down your pants." I take my work, my writing, seriously. Me? Not so much. After 30 years in the journalism game, I'm using this blog to step out from behind the third-person curtain. Opinion, essay, informed reportage...I can't guarantee what you'll see from day-to-day, but I promise I'll give it an honest turn and a unique take. Let me know whatcha think.
Thanks, as always, for your time and consideration,
Mat